You are the HIM director at Anywhere Memorial Hospital where the stakeholders have gathered to discuss their system-wide electronic health record needs. They currently have an eight-year-old hybrid emergency health record (EHR) system, but they would like to transition into a fully digital record.
During the initial EHR implementation, some of the legacy providers expressed their desire to keep some of the records on paper because using a computer on wheels (COW) was not an effective means of patient care. This hybrid system required full-time HIM employees to gather and scan these paper records into the system. This led to a problem of delinquent medical records because healthcare providers did not always get the records completed promptly. Delays also occurred when the document scanning system was down. Providers and healthcare professionals would not always have access to information needed in these paper records, so HIM staff would sometimes have to find the paper documentation and take it back to the patient care unit. This resulted in lost documents and misplaced patient records.
Now, there is a new CEO and a new medical director who are both major supporters of a fully digital record, which would require providers to enter patient information directly into the system. This would reduce the number of paper records being scanned into the system. There would be no need for a dedicated staff to retrieve and scan documents into the system. The younger physicians are thrilled at the idea of a record that they can see in real time to provide patient care. Legacy physicians are not happy about the change but realize that change is inevitable. The medical staffing office and medical director have identified a “physician champion” to advocate for the record transition and collaborate with the implementation team in creating a training plan for all providers. The CEO and medical director have assured the healthcare providers that they will have scribes available to assist with clinical documentation entry into the new system.
The main reason for this transition includes reducing the long turnaround times for completed medical records. This greatly affects the revenue cycle; the manual tracking of deficiencies, which is subject to human error; and the disorganization of records, which could lead to ineffective outcomes if all information is not presented. A fully digital record will automate deficiency tracking, alert staff when records are not completed on time, and keep records organized for easy access. A digital record also means that there will be no need for a policy for the destruction of paper records, which will prevent accidental deletion or overwriting of health and financial information.
As the HIM director, you are responsible for working with the IT team to streamline the processes to sundown the hybrid record and implement the new digital record. During this process, you will need to take into consideration the needs of the facility and the staff, as well the events that should be included in the System Development Life Cycle (SDLC) for this project. The transition from a hybrid to digital record will no longer require staff to pick up records from the floor post discharge. Neither will staff members be required to manually assign deficiencies. Retrained staff will need a keen eye for detail in order to recognize physician deficiencies and properly route records for correction. These changes mean you will need to revise the responsibilities for the new roles associated with the new digital system.
A. Using the information in the scenario, make up a plan for the transition to a fully digital record by doing the following:
1. Describe the issues with clinical documentation in the hybrid record.
2. Explain how a fully digital record will address and solve the issues caused by the hybrid record.
3. Describe how the roles of existing staff members in the HIM department will change with the transition from a hybrid record to a fully digital record.
4. Explain the revised roles and responsibilities of two health information management (HIM) professionals in the Systems Development Life Cycle (SDLC) for this implementation project.
As the Health Information Management (HIM) director at Anywhere Memorial Hospital, my primary responsibility is to facilitate the transition from a hybrid Electronic Health Record (EHR) system to a fully digital record. This transformation is driven by the need to address several critical issues that have plagued the current hybrid system. In this plan, I will describe the issues with clinical documentation in the hybrid record, explain how a fully digital record will solve these issues, detail the changes in roles for existing HIM staff, and outline the revised roles and responsibilities of two HIM professionals in the Systems Development Life Cycle (SDLC) for this implementation project.
The hybrid EHR system currently in use at Anywhere Memorial Hospital has presented several challenges:
a. Inefficiency in Document Retrieval: Legacy providers favored paper records due to difficulties using Computer on Wheels (COW) devices, resulting in inefficiencies in accessing patient information.
b. Delinquent Medical Records: Paper records necessitated full-time HIM staff for manual scanning, leading to delays in completing medical records.
c. System Downtime: Scanning issues during system downtime further hindered access to crucial patient data.
d. Lost and Misplaced Records: Manual retrieval and transport of paper documents occasionally resulted in lost or misplaced records.
Transitioning to a fully digital EHR will address and resolve these issues:
a. Real-Time Access: Younger physicians will have real-time access to patient records, enhancing patient care and reducing inefficiencies.
b. Elimination of Manual Scanning: With providers entering patient information directly into the system, there will be no need for dedicated scanning staff.
c. Improved Deficiency Tracking: The digital system will automate deficiency tracking and alert staff when records are incomplete, reducing human errors and turnaround times.
d. Enhanced Organization: Digital records will be systematically organized, ensuring all information is readily accessible.
e. Reduced Risk: Eliminating paper records removes the need for policies regarding their destruction, preventing accidental deletion or overwriting of sensitive information.
The transition to a fully digital record will bring about significant changes in the roles of existing HIM staff:
a. Record Retrieval: The role of manually retrieving paper records post-discharge will no longer be necessary, freeing up staff for more value-added tasks.
b. Deficiency Assignment: Staff will shift from manually assigning deficiencies to using the automated deficiency tracking system, requiring a focus on quality control and data accuracy.
Revised Roles in the SDLC for HIM Professionals: In the SDLC for this implementation project, two HIM professionals will play critical roles:
a. HIM Project Manager: This professional will oversee the entire transition process, ensuring that it aligns with organizational goals, timelines, and budget constraints. They will collaborate closely with IT and other departments, supervise the implementation team, and facilitate communication between stakeholders.
b. Clinical Documentation Specialist: This role will focus on developing and implementing a comprehensive training plan for all healthcare providers. They will work alongside the physician champion to ensure that all providers are proficient in using the new digital EHR system efficiently. Their responsibilities will include creating training materials, conducting training sessions, and providing ongoing support to address any issues or concerns.
The transition from a hybrid EHR system to a fully digital record at Anywhere Memorial Hospital is a critical step toward addressing the inefficiencies and challenges associated with clinical documentation. This transformation will not only improve patient care but also streamline HIM processes, reduce errors, and enhance overall data management. The revised roles and responsibilities of existing staff and the engagement of HIM professionals in the SDLC will ensure a smooth transition and successful implementation of the new digital EHR system.
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